CCR1992082COMMON COUNCIL - CITY OF MUSKEG0
RESOLUTION #82-92
AMBULANCE SERVICE PROVIDER REIMBURSEMENT
AUTHORIZE EXECUTION OF APPLICATION FOR
Tess Corners Volunteer Fire Department
WHEREAS, Wisconsin Act 102 provides supplemental funds to
ambulance services owned or operated by a volunteer fire
department; and
WHEREAS, ambulance service providers who plan to seek Act 102
funds must complete an "Application for Ambulance Service
Provider Reimbursement;" and
WHEREAS, the Finance Committee has recommended approval.
NOW, THEREFORE, BE IT RESOLVED that the Common Council of the
City of Muskego, upon the recommendation of the Finance
Committee, does hereby authorize the City Clerk to sign the
attached "Application for Ambulance Service Provider
Reimbursement" and all future applications of similar nature for
reimbursement of ambulance services.
DATED THIS 24TH DAY OF MARCH , 1992.
ID
SPONSORED BY:
FINANCE COMMITTEE
Ald. Daniel J. Hilt
Ald. Edwin P. Dumke
This is to certify that this is a true and accurate copy Of
Resolution #82-92 which was adopted by the Common Council of the
City of Muskego.
3/92cac
STI(TE OF WISCONS1N
EMS SECTION
1989 WI Aci 102
Name of Licensed Provider Number, 60 - i, 1
Phone: ('// L/ \ vz- - ,973"5
ISTATEI ,ZIPCODE>
1 PRIMARY/CONTRACT SERVICE AREA:
Please attach a map(s) which defines your prmarylcontracf service area(s). excluding mutual aid and back-up
territory
2. Total population sewed in Primary/Contract Area: /x #on
3. a. Name of.Contracting Agency: C I fy 0 4' /vl dX '9 c,
Address: f? 0, /f.i IC! 3 C
City. State, Zip Code: z- e I ,
b. Deslgnated contact person within contracting agency: /'A ;J LA I/,J z 5,L-d j1-L c
c. Contact Person Phone Number: ( 4/L/ \ t 77 . '//m
d. Municipal Code Number: 39 - hodboa3
4. TYPE OF SERVICE: (Check one box only.)
17 County 17 Town City 0 Vlllage 0 Indian Tribe
0 Nonstock, Nonprofit Corporation (Pursuant to Chapter 181 Wis. Statutes)
5. CLERK -- County, Town, City or Village or Prima Contract Service Area.
Name of Clerk: .),'=/A /l$rrucjP Signature:fl
Address: C. AkP qc-? Phone: (~) b74 - '%'fiC
6. AMBULANCE SERVICE PROVIDER:
By my signature, I certify that the proceeding information is true to the best of my knowledge and beliel. I further
certify that supplemental funds received by the ambulance service named above will not be used to replace or
decrease existing funds and that a report will be filed every 2 years with the DHSS beginning July 1. 1993, detailing
expenditure of recelved programs funds in compliance with 1989 Wisconsin Act
Name of Provider: ~P~'A;C s fL/ A(v /d~~x
Address: /:J;L/+ .?/- 7-?/ /FSC~~.- a7., , (4.n /
city. State, Zip Code: A'$P+&G%, /L'I
/
rz3/s-,
COUNTY CERTIFIED SURVEY MAP NO. I,
Part of Government Lot 2, sltuated ln the Southwest 114 and the Southeast 114 of
the ~orth~ebt 114 of SectLon 26, Townshlp 5 North, Range 20 East of the Fourth
~rlnclpal ~erldlan, Clty of Muskego, Waukesha County, Wisconsin.
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NOTE
Premred by
8AXTER8 WOODMAN INC.
V6N PINE STREET
BURLlNGTON. WI 53105
14141163-7834
job no, 920068
SCALE - , I": 120' ,I
olo X) 60 I20 240
NOTE: THE NORTH LlNE OF THE S.W. 114 OF
SECTION 26-5-20 IS BASED ON EXISTING DEEDS.
SURVEYS AND CERTIFIED SURVEY MAPS NO.'S
2062, 4240, AND DOCUnENT NO. 701576, VOL.
4, PAGES 332-333.
A&&l, h. fL4d%J
PATRICK R. SCHUSTER, RLS-1985
March 5, 1992
920068